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Home My WebLink AboutWiring Permit - Permits #13005 - 815 CHESTNUT STREET 12/19/2014 Date.,.......... .............................. OORTN "". 1:' TOWN OF NORTH ANDOVER PERMIT FOR WIRING A, gs� Co C U This certifies that .............................................../ .................................................. has permission to perform ........................- .................... ........ wiring in the building of....... 1 -'41/ ..............................................I.......................................... at q7A', ............................................................................ .,,.�,.North-Andover,Mass. 7—... "0 Fee...... ....................Lic.No. . ......... ...................... I ............... hLECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. kit BOARD OF FIRE PREVENTION REGULATIONS [Rev.Occupancy and Fee Checked 11/99] -- (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: p - 5 ) 4 City or Town of: "1',1 (', � (IN ( i L,�,J 6 cvY,, ,v-, To the—Inspector of Wires.- By this application the undersig�e tgives�no�i�of his �n to perform the electrical work described below. Location(Street&Number) �A Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead❑ Undgrd R No.of Meters Lftw Service Amps Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity c 4" Location and Nature of Proposed Electrical Work: L4�LR— v,y1n, t. - Comoletion of the.fiollowin, table may be waived by the Inspector Of Wires. No.of Recessed Fixtures No.of CeiL-Susp.(Paddle)Fans wo.-07- Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming pool ove in- -Emergency ENgTi7ing- —jernd. El grnd. ❑ IBNot-tery Units No.of Receptacle Outlets No - I -of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and - Total - Initiating Devices No.of Ranges No. of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eat Pump Totals: imber I Tons KW No.of Self-Contained Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local 0 municlpaf- ---- Connection El Other No.of Dryers Heating Appliances KW Secunity Systems: No. of Water of No.of- No.Aevices or Equivalent Heaters KW No. Signs Ballasts Data Wiling: No.of Devices or Eaulvalent No.Hydromassage Bathtubs No,of Motors Total HP Telecommunications Wi IOTHER: NO.of Devices or Equivalent Attach additional detail ifdejire,4 or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE El/BOND 171 OTHER [I (Specify:) Estimated Value of Electrical Work: — (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with NIEC Rule 10, and upon.c m, jetiQm pains an penalties ofiverjury,that t1re information on 1h1s application is true and complete. Teerd -4- - " - - -- '- --- - ' - - -"-- - -P I_o- p .& ndir Ike d' ' FIRM NAME: . ...... LTC. NO.:,, Licensee Signature LTC. NO.: f applicab1-7jwer�-,. .,,I the lJce1nseZumntber line.) Bus.Tel. No., ',jJS &:3, 1,-;,1 "Z Address: Of ILIA C,91AIt. Tel. No.: m aware does not have the liability insurance coverage normally- OWNER'S INSURANCE WAIVER: am aware that the Licenseet',�� required by law. By my signature below, I hereby waive this requirement. I am the(check one)n owner 11 owner's agent. Owner/Agent Signature "telephone No. WE.- $ ()o The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,A Please Print Legibly Name (Business/Organization/individual): ""To Cc-o Address: 29 C'ook— City/State/Zip: B t r-c e 2 t c.o,. MA of SZl Phone #: 9 7 13 6,lo 3 .0 Z 9 2 Are you an employer? Check the appropriate box: Type of project(required): 1.® I am a employer with- r7'1 4. ❑ I am a general contractor and I 6 ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees ees y These sub-contractors have P Y 8. [-1 Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp, insurance.t 9. ❑ uilding addition required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself.(No workers'comp, right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. (No workers' 13.❑ Other comp. insurance required.) *Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ,-�t Insurance Company Name: AQC e cse.-ut,ec-,-t-� was' „�,p�,�s,,�� SEA �,�swR C�Rour? i Policy#or Self-ins.Lic.# ABC.to- C OS O ZA --1 N Expiration Date: 1-4 /3-11+ Job Site Address. i ;' ...,i'� ' : .. d,t. ... ._ City/State/Zip: ,�� ,� �..�� ..��ry��,� �:�d�4'Pr'6 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. N Si ature: Date: Phone#: 9 78 -.5z8-E3 g 21 Official use only. Do not write in this area, to be completed by city or town official Xr City or Town:'' Permit/License# Issuing Authority (circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other _ Contact Person: Phone#: